John Fishel, who suffers from with a lung disorder, prefers liquid oxygen. The expense of providing liquid oxygen threatens its availability. (Adolphe Pierre-Louis/Albuquerque Journal)

John Fishel, 72, has been on oxygen therapy for about a year.

Now how he gets his oxygen has come into question.

A life-threatening fight with pneumonia and a recurring inflammation of his lungs cause him to gasp for breath if he goes without his supplemental oxygen for too long. Fishel, who retired from a career in the Navy and then worked locally in health insurance for many years, can’t leave home without a portable tank.

“I’m happy,” says Fishel in his South Valley home that he shares with his wife, Nancy. “Don’t feel sorry for me. This is inconvenient, but I have a backpack for my oxygen and it’s very portable.”

For people with lung conditions like Fishel, life-saving oxygen comes in a tank, prescribed by a doctor.

That can either be liquid oxygen or oxygen refined at home with an oxygen concentrator. Fishel can connect directly to the larger units with tubing that snakes through his house or hook up to a portable tank.

Fishel, who has health insurance through Medicare and his military benefits, has tried both kinds. He prefers the liquid oxygen, with its portable backpack unit, which he can fill from a barrel-size liquid oxygen canister in his bedroom. He says it’s more convenient and less expensive.

Home oxygen concentrators also come with supplemental canisters of oxygen in larger and smaller portable tanks. However, the size Fishel had on a wheeled cart was cumbersome and the supply didn’t last as long as his liquid oxygen backpack. “It’s difficult to tow the tanks and push a shopping cart at the same time.”

He says his electricity bills increased $40 a month and more with the oxygen concentrator unit he was provided.

When his lung disorder gets worse and he can’t meet his body’s requirements for oxygen, he says he struggles more to breathe with the oxygen concentrator than he does with his liquid oxygen.

Recently he learned that his liquid oxygen could be in jeopardy and he could be forced to return to an oxygen concentrator.

Nationally, many support groups for people with respiratory problems are reporting that they have trouble getting liquid oxygen. They have been told liquid oxygen is no longer available and have been switched to an oxygen concentrator or their supply had been reduced.

Bob Nelson, vice president of operations at HME Specialists, shows a truck with a liquid oxygen delivery system. Delivery costs drive the cost of liquid oxygen higher than it is reimbursed by Medicare, suppliers say. (Adolphe Pierre-Louis/Albuquerque Journal)

It’s no great mystery: Durable medical equipment providers have greater expenses for liquid oxygen compared with an oxygen concentrator, national and local sources say. With declining reimbursements from Medicare, and with a growing population of people on the government health plan, liquid oxygen is less attractive for suppliers.

“Liquid oxygen is a much more expensive form of oxygen than gas. Liquid oxygen is more desirable because it is a more compact form and the equipment is smaller,” says Jason Sharp, a manager at Presbyterian Health Plan. “Because of Medicare competitive bid, durable medical equipment suppliers are facing a smaller profit margin due to Medicare’s much lower rates.”

However, he says it’s not an issue for members on the Presbyterian Health Plan, because its suppliers haven’t had the same rate reduction as Medicare suppliers.

Dr. Ronald Bronitsky, a pulmonologist with Presbyterian Medical Group, says despite its expense to suppliers, liquid oxygen has several advantages for patients, including that it’s quieter and requires no electrical expense to have it at home. It also seems less drying to nasal passages than concentrated oxygen: “Liquid oxygen’s advantage, first and foremost is its easy portability and much lighter tanks for patients to carry,” he says. “Important for our patients with limited lung power.”

Fortunately for Fishel, his physician has specifically prescribed liquid oxygen, so his supplier must provide him with that kind of oxygen, based on its contract with Medicare, according to Marilyn Jackson, a press officer with the Centers for Medicare and Medicaid Services (CMS).

According to those rules, an enrolled supplier may not discontinue liquid oxygen for existing beneficiaries unless particular conditions are met. Those are patients who have been renting equipment for five years, those who no longer medically need oxygen, those who have moved outside the supplier’s service area or those who choose another supplier, she says.

Also, contracted suppliers must furnish liquid oxygen to new patients in designated areas who have a prescription for liquid oxygen, Jackson says.

Dave Evans, a vice president at HME Specialists on Osuna NE, shows a small oxygen gas tank; a larger portable oxygen gas tank is on the nearby cart. A portable liquid oxygen tank is in the foreground. (Adolphe Pierre-Louis/Albuquerque Journal)

Reimbursement

Mason L. Wells, CEO of HME Specialists LLC, a local durable medical equipment provider on Osuna NE, says he delivers both kinds of oxygen to his clients, but liquid oxygen costs more to provide than he is compensated.

“Some providers have decided they will no longer provide liquid oxygen to their patients because the cost to deliver and service liquid patients is far greater than reimbursement,” he says. “New technology in oxygen concentrators can now do anything that liquid oxygen can do.”

Dave Evans, a respiratory therapist and vice president at HME Specialists, says a newer blue oxygen concentrator, a little larger than a carry-on suitcase, performs more efficiently and more quietly than older units.

Wells estimates the electrical cost to run the newer oxygen concentrators at about $15 to $35 a month.

Smaller supplemental tanks of oxygen gas, already filled for clients, also backpack size, may not last as long as a liquid oxygen unit, but clients can bring several tanks along wherever they go, he adds.

Liquid oxygen is expensive for companies like his because they have to hire someone with a commercial driver’s license and maintain more equipment to fill the liquid oxygen canisters at clients’ homes about once a week, he says.

They are also subject to federal regulations that don’t apply to the delivery of the oxygen concentrators.

Those can be delivered without all the special considerations and then supplemented with pre-filled tanks. Empties are traded for full tanks about once a month, saving expense, Wells says.

“Today’s reimbursement climate finds many providers losing money to provide concentrators and portable oxygen,” Wells says. “We must acknowledge their need to make difficult business decisions when necessary. The alternative is to increase the number of business failures among providers, which leads to access of care issues among our state’s patients.”

Erika Sward, a national advocate with the American Lung Association in Washington, D.C., says the problem of liquid oxygen versus oxygen concentrators is “a perfect storm,” because financial considerations may at some point outweigh a person’s quality of life issues.

“We can’t just give people a huge tank and a long cord and tell them to stay home,” she says. “Is a patient able to go out as they had been? Can they do what they want to do? Oxygen delivery needs to be compatible with lifestyle.”

“The issue of liquid (oxygen) is a tough one,” says Phil Porte, executive director of the National Association for Medical Direction of Respiratory Care in Virginia, explaining the Medicare rules that a supplier must deliver liquid oxygen if the physician specifically orders it.

But often the supplier tries to talk the physician out of liquid oxygen and may eventually say it is not available, he adds.

However, a persistent physician can get liquid oxygen for his patient. “The price of liquid revolves around delivery costs, not inherent capital cost. Bottom line, an insistent physician and a well-meaning beneficiary ought to be able to get liquid, fully aware it is a loss leader for the supplier.”

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